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PLACE LETTERHEAD HERE AND REMOVE NOTE
Note: This form is intended as a sample form of the information that you as the surgeon should personally
discuss with the patient. Please review and modify to fit your actual practice. Give the patient a copy and
send this form to the hospital or surgery center as verification that you have obtained informed consent.
PERMANENT PUNCTAL OCCLUSION CONSENT FORM
CONDINTION AND PROPOSED TREATMENT
My ophthalmologist has diagnosed me with dry eye syndrome. Typical symptoms of dry eye syndrome
include dryness, burning, tearing, a sensation that something is in the eye, inability to read for
prolonged periods of time, and fluctuating vision. In many cases, dry eyes are caused by the body’s
failure to produce enough tears. Treatment of dry eye syndrome includes attempts to increase the
lubrication of the eyes by using artificial tears and ointments, or by blocking the tear drainage ducts to
slow down the loss of tears from the surface of the eyes.
Permanent punctal occlusion involves the use of thermal cautery (heat) or a laser to close the opening
to the tear drainage duct. This procedure is usually permanent, and not reversible. It is usually
recommended in patients that have had success with various types of punctal plugs. Punctal occlusion
can be performed on the lower eyelids, upper eyelids, or both upper and lower eyelids.
RISKS OF PERMANENT PUNCTAL OCCLUSION
The risks of permanent punctal occlusion include:
1. Infection from the localized damage to the eyelid.
2. Increased tearing because the tears can no longer drain away from the eye.
3. Scarring of the eyelid margin.
4. Irritation at the site of the punctum, especially while healing.
5. Inability to reverse the operation because of permanent damage to the lining of the punctum
and canaliculus (the entire length of the tear drainage duct in the eyelid.
ALTERNATIVES TO PERMANENT PUNCTAL OCCLUSION
The alternatives to permanent punctal occlusion include:
1. Artificial tears and ointments. Intensive topical lubrication of the eye with frequent instillation of
artificial tears and ointment provides some relief of dry eye symptoms. It is often not sufficient by
itself in moderate to severe cases.
2. Restasis®, or other topical anti-inflammatory or immune modulating drops, can reduce ocular
irritation and increase tear production in some cases.
3. Nutritional supplements such as omega-3 fatty acids and fish oils can reduce ocular inflammation
and dry eye symptoms.
4. Temporary punctal occlusion can increase the moisture on the ocular surface but the punctal plugs
can cause irritation or fall out, and the dissolving intracanalicular collagen plugs dissolve after
several months.
5. Observation without any treatment is a possible choice, but you will be forced to live with the
symptoms of dry eye syndrome.
Version Nov. 2013, Translated June 2014
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I understand that it is impossible for the doctor to inform me of every possible complication that may
occur. By signing below, I acknowledge that I have read and understood the above information, had the
opportunity to discuss this information with my doctor to my satisfaction, and agreed to proceed with
permanent punctal occlusion of (please circle):
RIGHT lower upper
LEFT lower
upper eyelid(s)
_____________________________________________________________________________________
Patient Signature (or Person Authorized to Sign for Patient)
Date
Version Nov. 2013, Translated June 2014
2